Introduction to Healthy Aging: Trends in Aging and Impact on Nursing and Health Care

Module 1-A: Introduction to Healthy Aging: Trends in Aging and Impact on Nursing and Health Care O1: Discuss societal aging changes in America and globally; changing demographics and rationale, life expectancy, population decline, work and retirement, sources of income, and expenditures ● Note: Median population age is growing due to better healthcare, increase life expectancy, increase fertility (birth rate) after WWII ● Chronological late life is recognized as beginning somewhere between ages 50 and 65 ● Trend 1: Age of global populations - global aging is growing rapidly ○ In ~2016/2017 the percent of the global population that is over 65 was about the same as the percent of the global population that was under 5 years of age ■ Prior to this, there were many more children under 5 than adults over 65 - now it is trending in the opposite direction ○ Rates of adults over 65 are increasing! - at 2 billion up from 900 million in 2015 ■ In 2050, will exceed 15% of global population ○ Rates of children under 5 are decreasing ● Trend 2: Increasing life expectancy ○ Life expectancies differ based on sex and race ○ Hispanic men and women have the longest life expectancy out of all ethnicities ■ At Age 65: ● White women have greatest ● Followed by black women ● White men are second to last ● Black men have the shortest life expectancy ■ At age 85 ● White women and black women have ~equal life expectancies and are expected to live longer than men ● Black men and white men also have ~equal life expectancies and are expected to live shorter lives than women. ■ Note: Japan has the highest life expectancy -- women in both races have the greatest life expectancy ● Trend 3: There is a rising rate of the “oldest of the old” ○ The super-centenarians=at least 110 yrs of age ○ Centenarians=100-109 ○ % of those older than 100 yrs is raising more rapidly than the total population in many countries ○ Those over 85 are increasing ■ Baby boomers (born between ) will reach this age by 2030 ■ Expected to more than double between from 6 million to 14.6 million ■ The ability to produce penicillin and other medications has significantly influenced the survival of baby boomers ○ As are those over 65 ● Overall: Numbers of aging patients are rising, and populations are decreasing - up to 75% of nurses time will be spent with older adults ● Trend 4: Sources of Income ○ Social security is greatest source of income - increasing ■ 34% ■ Problems with sustainability - social insurance systems ○ Earning are second greatest - increasing ■ 29% ○ Asset income is 3rd ■ 15% ○ Pensions are last ■ 12% ● Trend 5: Expenditures ○ Housing is greatest expense ■ 37% ○ Healthcare ■ 16% ○ Transportation ■ 14% ○ Food ■ 12% ● Trend 6: Work and retirement ○ Quick to die shortly after retirement O2: Analyze socio-economic and cultural changes in America which impact the need of cultural competence ● Trend 1: Heterogeneity in aging ○ Older adults are heterogeneous ■ Each individual is unique - make no generalizations ○ Older adults increasing ■ Aging increase 15% in 2015 - 19.6% in 2030 ■ More older females than males ● Trend 2: Racial/ethnic composition ○ Comprise of 42% of 65 and over (20% today); ethnically older adults are poorer ○ Now, the majority of people over 65 are white folks (Will drop from 78% in 2014 to 55% in 2060) ■ Hispanic/Latino populations are the biggest growing demographic among the elderly. (increase of 14%!) ■ Black folks are also a growing demographic! ● Trend 3: Marital status ○ Lower % of older women married ■ Decreases with age ○ More older men are married ■ Typically men throughout adulthood are married ● Trend 4: Educational attainment ○ Most older adults tend to have a HS level education, but minority have college degree ■ 84% graduated from HS ■ 27% have baccalaureate degree ○ White people have the highest rate of HS graduation ■ 89% ○ Asians have lower rate of HS graduation (similar to black individuals), but higher rate of baccalaureate degree ■ 34% ● Trend 5: Living arrangements ○ Less women live with a spouse ■ Women tend to live alone or with “other relatives” at much higher rates than men ■ Older women that live alone tend to be poorer ○ Living arrangement differences among racial/ethnic groups ■ Black men and women live alone at the highest rates of any race/ethnic group ● They also have the lowest rates of living with spouses ● Greater rate among women ■ Asian men and women live with their spouses at the highest rates ○ 40% still married and living in their own homes ● Health status varies and is highly complicated! (increase of 4%) ○ Causes of death tend to be chronic - mixture of many ○ They’re influenced by income, education (vary greatly), living arrangements, and need for support ● Cultural competence is REQUIRED!! ○ Nursing responsibility - to provide competent care to persons with different life experiences, cultural perspectives, values, styles of communication and ages from their own ■ Ethnocentricity - impacts communication and is influenced by age, culture, ethnicity ■ Cultural competence - awareness, knowledge and skills ■ Cultural humility ■ Health disparities ■ Health inequities ○ The LEARN Model ■ L- Listen- carefully to what the elder is saying. Attend to not just the words but nonverbal communication and meaning behind stories ■ E-Explain-your perception of the situation and the problems ■ A-Acknowledge-and discuss both the similarities and the differences between your perceptions and goals and those of the elder ■ R-Recommend-a plan of action that takes both perspectives into account ■ N-Negotiate-a plan that is mutually acceptable O3: debate the ways in which aging is defined ● Defining age chronologically ○ Pre elderly 55-64 ○ Young-old 65-74 ○ Middle-old 75-84 ○ Oldest-old 85+ ○ Frail old 85+ at risk ○ Elite old 95+ ○ Centenarians 100+ (longevity outliers) ● Defining age functionally ○ Looks at function rather than actual age in years ○ The largest percentage of seniors who have limitations have limitations performing 1-2 ADLs ○ The second largest group experience limitations with only IADLs. ○ Differs culturally ● Old is defined in terms of personal attitudes, culture, and experiences ● Societal view: high value on youth - low value on age ● Ageism ○ “Prejudices and stereotypes that are applied to older people merely on the basis of their age” ○ Reasons for growing ageism ■ Gerontophobia - unreasonable fear or irrational hatred of older people - increase in cultural diversity will change this ■ Outcomes of ageism ● Slides refer to page 47 Box 4.3 but that box talks about spirituality? O4: Discuss the relationship between aging, health, and well-being ● Growing burden of non-communicable or chronic disease - shift in disease epidemiology ○ Leading causes of mortality ■ Heart disease - decreasing ■ Cancer ■ Stroke ■ Flu/Pneumonia ■ Diabetes ■ Unintentional Injuries ■ AD ■ Chronic lower respiratory disease ○ Leading causes of morbidity is ■ HTN ■ Arthritis ■ Heart disease ■ Cancer ■ DM ■ Asthma ■ Stoke, chronic bronchitis or emphysema ○ Sensory impairments and oral health ■ Men have higher rate with trouble hearing ■ Women and men are almost the same with trouble seeing - women are slightly higher ■ Approximately equal among men and women with no natural teeth O5: Explain the impact of aging trends on health care ● Older patients are a hospital's core business ● Disproportionate need for hospital care of older adults ● People over 65 make up ~15% of the population ○ They make up ~50% of hospital admission and ~70% of acute care admissions ● By 2020, 75% of nursing time will be spent with older adults ● Older adults are 13% of the population, but they’ll account for the majority of healthcare resources ○ They will also contribute to higher rates of readmission within 30 days ○ Will stay in the hospital for longer stays on average ○ 90% of nursing home facilities ○ 50% of home care services ○ 60% of adult primary care visits ○ 50% of speciality ambulatory care visits ○ 34% of prescriptions O6: Discuss the history of gerontological nursing specialties, education and certification, including interdisciplinary care ● Nursing - first profession to develop scope and standards of gerontological care (1970) ● Gerontological nursing certification (1974): American Nurses Credentialing Center ● Gerontological nursing certification ○ Requires active RN license ○ 2 years full-time RN practice ○ Greater than or equal to 2,000 hours (gero nursing in 3 years) ○ 30 hours of CE (gero nursing) in 3 years ● APRN roles (2012) ○ AG-ACNP ○ AG-PCNP ○ AG-CNS AG-ACCNS ● What is the difference between geriatric nursing and gerontological nursing? ○ Geriatric - disease ○ Gerontological - improvement in QOL ● Gerontological nursing education ○ 1997: mandated gerontological nursing content in UG and Grad curricula and CE (only ⅓ have “stand alone” course) ○ Education has improved but still nurses are not adequately prepared to care for older adults ○ 2000/2010 AACN/Hartford: care competencies, care knowledge and role development ○ 2010: Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation ○ IOM proposed interdisciplinary care by interprofessional teams O7: Identify resources available and nursing organizations devoted to improving care and research related to older adults ● Hartford Institute of Geriatric Nursing - Consult GeriRN “Try this” series ○ Initiatives in nursing education, nursing practice, nursing research, and nursing policy include enhancement of geriatrics in nursing education programs through curricular reform and faculty development ● Professional organizations ○ GSA - interdisciplinary collaboration/research ○ AGHE - education preparation ○ AGS - improve health and wellbeing of older adults ○ NICHE ○ JHU SON Geriatric Interest Group (GIG) ● The AACN and The Hartford Institute for Geriatric Nursing published the Recommended Baccalaureate Competencies and Curricular Guidelines for the nursing Care of Older adults ○ Despite these lists of competencies there remains a lack of consistency among nursing schools in helping students gain needed gerontological nursing information and skills ○ Faculty with expertise in gerontological nursing are scarce and there is a critical need for nurses with master’s and doctoral preparation and expertise ● Research ○ Focus of research: A shift in view of aging to one that centers on the potential for health, wholeness, and quality of life, and the significant contributions of older people to society ○ Receives considerable funding from the National Institute of nursing Research (NINR) Module 1-B: Successful aging and what we know about promoting healthy aging: primary and secondary prevention (online) How is health defined? ● Health is a context for activities that provide meaning for late life ● Health conditions → perceived as problems when they interfere with important activities ● Older adults compare themselves to their peers (not younger people when rating their health ● Social aspects of health and values cuh as reciprocity are meaningful - when looking at health status O1: Discuss terms related to expectations for aging: successful aging, active aging, quality of life, healthy aging ● Biochemical model of successful aging ○ Avoidance of disease and disability ○ Active engagement with life ○ Maintenance of high physical and cognitive function ○ Negative aspects of this model: one must be free of disease and in good health - most older adults do not age successfully according to this model ● Secrets of aging ○ Protective factors: no smoking, drinking and driving, regular exercise, moderate weight, education, lower BP, stable marriage, mature defenses (resilience) ● Determinants of healthy aging and quality of life ○ What determines how one adjusts to aging? ■ Gender (females live longer) ■ Culture (how aging is viewed) ■ Behavior (promotion of healthy lifestyle - males tend to have more negative behaviors plus hard labor) ■ Personal factors (intelligence and motivation) ■ Physical environment ■ Economic and social service systems ■ Important areas to focus on when working with older adults for maximizing health and function ● Important areas to focus on when working with older adults for maximizing health function ○ Self-management of chronic disease – preventing complications of existing illness/disease ○ Sleep ○ Spirituality ○ Sexuality ○ Social engagement ○ Exercise ○ Nutrition ○ Humor ● What is “quality of life” for older adults? ○ QOL → physical well-being, psychological well-being, social well-being, and spiritual well- being (factors older adults identified over time) ● What is the meaning of QOL? ○ Maintaining and improving QOL = major nursing focus ○ A person’s physical health, psychological state, level of independence, social relationships, personal beliefs, and relationships to salient features in the environment ○ Individual’s perception of his/her position in life in context of the culture and value system – in relation to goals, expectations, standards, and concerns ○ Good social relationships and good health (important component) O2: Analyze 4 major factors that define how older adults define a “good old age” around the world ● A “good” old age: How do older adults around the world define it? ● Project A.G.E compared aging in 7 countries around the world ○ 4 consistent themes – consistency does not equal uniformity ■ Physical health and functioning ■ Material security ■ Family ■ Sociality ● Physical health and functioning ○ Having the capacity to do things ■ Energy, vitality and interest in activities (US) ■ Being able to work, see and be strong (Africa) ■ Health is expected to decline with age (Ireland) ■ Doing things, they had always done – Activity theory (Hong Kong) ■ Health = often the context for activates that provide meaning ● Material security ○ Does not = wealth ○ Defined as satisfaction of basic physical requirements such as shelter, warmth, and protection against the environment ○ Different meanings with context ■ Africa = food ■ Ireland = pensions ■ US = material accumulation ● Family and sociality ○ Family ■ Africa = physical and material support ■ Ireland and US = companionship, confidants and trust ■ Hong Kong = filial responsibility ○ Sociality: qualities that facilitate interactions between self and others (reciprocity is important) O3: Describe levels of prevention and methods for determining appropriateness related to aging ● Levels of Prevention: ○ Primary prevention (pre-pathogenesis – health promotion) ○ Secondary prevention (halt disease progress – prevent complications – restore health) ○ Tertiary prevention (reduce/limit impairments – irreversible condition) O4: Review US guidelines established to guide preventative services and to promote health aging for older adults ● Prevention: ○ Preventative health measures are determined by benefit to health conditions and remaining life expectancy ○ Health can be categorized a robust (greater than or equal to 5 years life expectancy), frail (less than 5 years life expectancy), moderate dementia (2-10 year life expectancy), or end of life (less than 2 year life expectancy) ○ Tools available to estimate remaining life expectancy and guide screening decisions ○ Important to discuss limitations and risks of screening with patients who have short life expectancy - used to help determine risk/benefit ratio ■ Focus on preventive measures such as fall prevention and immunizations O5: Identify specific preventive services that are recommended for older adults based on their remaining life expectancy and cognitive status ● Prevention needs to be individualized based on: ○ Patient health/prognosis ○ Function ○ Risk of disease ○ Preferences ● Healthy lifestyle counseling ○ Considering clinical condition and personal habits, counsel older adults about: ■ Nutrition and maintaining normal weight – weight at each visit and height annually ■ Physical activity – annually ■ Alcohol misuse – initially, then if symptomatic ■ Smoking cessation – every visit ■ Sexual dysfunction and STIs – routinely/annually ● Physical activity ○ Emphasize advantages: promotes mobility, reduces rates of CAD, osteoporosis, many other diseases and disorders ○ Recommend a program that balances exercise for: ■ Endurance (walking, cycling) ■ Flexibility (stretching) ■ Strength (weight training) ■ Balance (Tai Chi, dance) ■ Note: should have a balance between all of these ● Immunizations (nurses should be aware of these) ○ The following should be a routine part of preventive healthcare for all older adults: ■ Influenza vaccine - annually ■ Pneumococcal vaccination - age 65 years ● One dose of pneumococcal conjugate vaccine PCV13 and one dose of pneumococcal polysaccharide vaccine PPSV - 12 months apart ■ Tetanus-diphtheria booster every 10 years ● All patients should receive 1 dose of Tdap (tetanus, diphtheria, acellular pertussis) ■ Herpes zoster vaccine once after age 60 - should be offered to every older adult ● Chemoprophylaxis ○ Calcium and vitamin D - recommended ■ USPSTF: ● Insufficient evidence to recommend combined vitamin D (greater than or equal to 400 IU) and calcium supplementation (greater than 1,000 mg) for the primary prevention of fractures or other diseases ■ In a meta-analysis published after the USPSTP review, high-dose supplementation of vitamin D (greater than or equal to 800 IU daily) was associated with prevention of hip and non-vertebral fractures in adults greater than or equal to 65 years old (SOE = A) ■ Institute of IOM states: ● Assuming minimal sun exposure, the recommended daily allowance to meet or exceed the vitamin D needs for 97.5% of the population is daily dietary intake of 600 IU in adults 50-70 years old and 800 IU in adults 70 years old ● Most adults can reach these targets through sun exposure or dietary intake (such as fatty fish, cod liver oil, dairy products, fortified beverages and foods); however, the targets may be difficult for some adults greater than or equal to 70 years old. And vitamin D supplementation should be considered ■ Dietary intake of 1,200 mg/d of calcium in women 50 years old and men 70 years old, and 1,000 mg/d for men 51-70 years old ○ Multivitamin - consider ■ USPSTF concludes there is insufficient evidence to recommend a multivitamin for prevention of CV disease or cancer ■ The 2010 dietary guidelines for americans suggest that nutrients should come primarily from eating a diet rich in fruits, vegetables, whole grains, fat-free and low-fat dairy products, and seafood ○ Hormone therapy - NOT recommended ● Cancer screenings ○ Screening for breast cancer ■ Look at guidelines for mammography with robust patients (greater than or equal to 5 year life expectancy) - pros and cons of every 2 years ■ Perform clinical breast exam (CBE) (frequency?) ■ No clinical trials have evaluated CBE without mammography ■ Screening mammography for survival benefit in women greater than or equal to 75 is unknown ■ No compelling evidence that BSE reduces M and M ○ Screening for colorectal cancer ■ FOBT (fecal occult blood test) annually or sigmoidoscopy every 5 years (greater than or equal to 50 years old) ■ Colonoscopy at age 50 and every 10 years to age 75 ■ USPSTF recommends against routine screening in adults greater than or equal to 75 years old and against ever screening adults 85 years old or older, because risks outweigh the benefits ● Increasing prevalence of colorectal cancer with age, but increasing harms of colonoscopy with age ○ Screening for prostate cancer ■ ACS and AUIA recommend discussing potential benefits and possible harms of screening with men 50 years old or older who have 10 year life expectancy ■ USPSTF (2012): recommends against screening for prostate cancer O6: Discuss recommended additional preventive activities and services that are potentially beneficial for older adults Test Recommendation DEXA for osteoporosis Once after age 65, or 60 if high risk Blood glucose Screen those with BP 135/80 mmHg Cholesterol Consider for age 65-79 years with additional risk factors AAA ultrasound Once for men 65-75 years who ever smoked Thyrotropin Consider every 25 years (insufficient evidence) BP Consider each visit Height Annually Weight Each visit ● Screening for alcoholism ○ Screen all older adults at least once ○ Use screening questionnaire (AUDIT) ○ Screen whenever a drinking problem is suspected ● Smoking cessation ○ Discuss with smokers at each visit ○ Emphasize that cessation at any age reduces rate of COPD, many cancers, CAD ○ Designate quit date and provide close medical follow-up ● STIs and sexual dysfunction ○ Screen older adults at high risk (those with a history of STI and those with multiple sexual partners) for STI and HIV ○ Provide high-intensity behavioral counseling (multiple sessions) to prevent STI for older adults at high risk ○ 50% of sexually active older adults report at least one bothersome sexual problem ● Screening for geriatric syndromes ○ Predictors of geriatric health Issue Screening recommendation Falls Annually Incontinence Annually Cognitive status If symptomatic Depression Annually Vision Annually Hearing Annually Nutrition Obtain weight each visit and height annually; calculate BMI Mistreatment of older adults Question with clinical suspicion Safety and preventing injury Check smoke detectors and carbon monoxide detectors, check water heater temperature, use sun protection, test driving skills, wear seat belts, complete advance directives and determine healthcare proxy ● Why do you stop screening? ○ Initiate and re-initiate discussions about stopping screening ○ Estimate patient life expectancy and its impact on benefits/harms of screening ○ Clarify values ○ Focus on mesure that benefit patients within their estimated life expectancy - with values taken into mind Module 2A Towards an Understanding of the Biology of Aging, Frailty and Vulnerability 01: Describe the biology underlying the aging process from theoretical perspectives ● Age-related biological Changes ○ Irreversible ○ Genetically programmed ○ Complex ○ Heterogeneous-don't all happen at same time and pace for all individuals. All patients at the same age look differ. Lots of variation. Genetic Theories ● Predetermined genetic program for life span ● 50 cycles of cell reproduction, then abnormalities follow-fibroblast ● Telomere shortening important component of this ○ Telomeres are ends of chromosomes that fray with continued DNA reproduction ○ Shorten with age, predisposing to mistake genetic messages ● 70-80 year olds pushed up or down based on environment ● Epigenetic-related to how chromosomes bind together-methylation ○ Age and environmental influences alter the way that chromosomes are bound together ○ Result in altered gene expression in older or sicker organisms ○ Sticky areas become more sticky thus can’t transcribe or genes get expressed more often Hayflick’s Theory ● Age related changes are: ○ Deleterious-changes are pathophysiological ○ Progressive-irreversible problem ○ Intrinsic (not environmental)-can be influenced by environment ○ Universal (all members of species) Wear and Tear Theory ● This theory is becoming more accepted-damage to cells ● The younger you are the increase in rate of fixing the older you are the more debris accumulates ● Components of cells wear out with time ● Components susceptible to environmental insult ○ Examples: diet, smoking,alcohol, activity level ● Autophagy: recycling program of cell that degrades damaged components-fails with age because of increased debris ● This recycling process begins to fail with age, leaving accumulations of damaged cellular components behind ○ Parkinsons ○ Huntington's Immunity Theory ● Involves inflammatory, cellular, and adaptive components ● Involution of immune system components ● Fewer defenses against invaders-increase risk for infection ● Poor response to vaccines ● Abnormal activation of immune system against self (autoimmune diseases) Cross-Link Theory ● Happens to some individuals and not others ● Chemical reactions bind DNA ● Proteins and DNA produced abnormally ● Gradual accumulation leads to organ damage and disease (skin and artery damage) Free Radical Theories ● Linked to the theories and can be tested in many different ways ● One of the most robust and observable scientific theory on biology of aging ● Biology may underlie many of the less robust theories ● Unstable oxygen compounds produced in normal metabolic process in mitochondria ○ Popped mitochondria leaks free radicals ○ Most converted to harmless byproducts ○ Converted by complex system of antioxidant enzymes (glutathione peroxidase) and antioxidant nutrients (vitamin C, carotenoids, selenium) ● Free radicals that escape degradation by this system cause direct damage to fat, protein, and carbohydrates ● Free radicals can pathologically alter gene expression-changes things in tissues ● The more free radicals one has decreases systems to recycle-starts cycle of decline in tissue-disease- death ● Protective mechanisms may decrease with age ● More toxic compounds escape to cause damage ● Tissue damage, altered gene expression accelerates aging=disease Neuroendocrine Theory-Physiologic ● Glands and hormones change with age triggering pathology ● Estrogen and testosterone declines contribute to bone, skin, and muscle changes with age ● Growth hormone and DHEA (adrenal androgen) declines underlie some sarcopenia ● Happens more in women than men ● Altered neurotransmitter and sympathetic nervous system activity may be pathologic in aging ● Thyroid hormone is unchanged Apoptosis Theory ● Process by which cells undergo pre-programmed cell death-triggered by debris ● Biologic process very well studied ● Normal process throughout life, but accelerates with age ● Specific cells targeted in embryo ● Prevents malignancy evolution ● Abnormal acceleration explains several aging-related diseases including Parkinson’s O2: Use clinical cases to help conceptualize frailty and aging-related vulnerability Refer to PowerPoint slides O3: Discuss factors that impact longevity and active life expectancy Important Factors for Longevity: ● Genes ○ Family history is often the most important factor ○ Low chronic disease burden ● Environment ○ Lack of smoking ○ Low alcohol intake ● Activity ○ Physical ○ Sexual ● Social setting ○ Education ○ Socioeconomic status ○ Coping skills and ability to be flexible ○ Social connectedness ○ Access to medical care ○ Depression and support ● Physical and cognitive abilities are the most important factors Important Factors for Active Life Expectancy: ● Attempt to determine how long someone will live ● Determination of average life span if already older ● May be able to determine this by longevity factors O4: Analyze the value of these theories and the rationale for using multiple theories of aging for explaining the complex phenomena of the aging process Important points: ● Disease and aging interact-tissue changes can lead to disease states ● Aging makes disease more likely-increase vulnerability ● Disease accelerates aging process-increase in free radicals, apoptosis, failed autophagy ● Heterogeneity-varies between individual and between organ systems Why Does it Matter: ● Older adults are at higher risk for poor outcomes ○ Functional decline, falling, death, nursing homes ● Slow recovery rate ○ Hospitalization, fractures ● Have the most iatrogenic complications ○ Meds, procedures, PT ● Highest mortality rates ○ Fragile and frail-die easily ● Biological aging, along with parallel disease process makes frail older adults highly vulnerable to adverse health outcomes and death ● Targeted care benefits this vulnerable subset of adults-protect from adverse outcomes Module 2-B: Sociological, Psychological, Developmental and Nursing Theories of Aging: Phenomenon of Aging O1: Discuss the usefulness of utilizing a theoretical perspective to understand aging ● Why do we need theories? ○ Help to understand relation of constructs ● Good gerontological theories - how are they useful? ○ Integrate knowledge, ability to predict - specific to guide nursing care within given setting ● Aging theories originated from psychosocial theories ● Review of biologic theories ○ Stochastic (error) - random events over time ■ Free radical ● Explains that unstable oxygen compounds, resulting from oxidative stress and modification of proteins, causes alteration of gene expression and cellular damage to DNA, lead to aging changes ● Example: atherosclerosis, cataracts, cancer ■ Cross link ● Explains aging as an outcome of chromosome interference with protein and DNA synthesis caused by methylation, resulting in abnormal cell production and accumulation of abnormal proteins ● Stiffening of protein due to glucose attachment - decrease function ■ Wear and tear ● Attributes aging to repeated use and injury to body parts over time; the capacity for repair is exceeded by “wear and tear” to the body part - loss of function results ● Example; osteoarthritis ■ Note: accumulation over time ○ Non stochastic (programmed) - predetermined ■ Genetics ● Is best explained as the lifespan for animals and humans is predetermined by a “biological clock” in which telomere shortening results in abnormal cell reproduction, thus cell replications are limited in number ■ Hayflick’s (apoptosis) “flick pop” ● The process in which cells undergo acceleration or senescence, resulting in inappropriate programmed cell death with age ■ Neuroendocrine ● Describes the HPA (hypothalamic/pituitary/adrenal) axis as primary regulator of aging process ■ Immunity ● Describes a decreasing defense against invaders of the body that occurs with age, resulting in abnormal activation of autoimmune diseases and involution of the thymus gland ■ Note: Integrate biological theory and nursing care ● Allostatic = process of achieving stability/homeostasis O2: Compare similarities and differences between sociological, psychological development and nursing theories of aging ● Sociological theories of aging ○ Explain how society influences older people and how older people influence society - and how they adapt ■ Changing roles, status, and relationships as people age ■ Pattern of responses among similar cohorts ● Disengagement theory ○ Stimulated much controversy - age discrimination ○ Adults gradually disengage ○ Reciprocal withdrawal between older adults and society (mutual) - circular, equilibrium ○ Allows transitioning of social responsibility to young ○ Criticism: no consideration for social and environmental factors ○ This theory is no longer supported because no evidence with environmental factors ● Activity theory ○ Successful aging = engaged and involved in life ○ Staying active → psychological and socially fit ■ Successful aging requires activity - social roles ■ Remaining produced = happiness ■ Earlier activity in life is better (middle life) ○ Activity and social engagement - affirm self concept ■ Social role participation --. Positive adjustment ○ Inactivity → decreased self concept and QOL ○ Criticism: activity is not always a choice ● Social exchange theory ○ Challenged both activity and disengagement ○ Cost-benefit model of social participation ○ Older adults may become unequal partners - too dependent on society and no longer contributing - may withdrawal and isolate ○ Negative reciprocity = inability to contribute (view help as necessary “payback”) ○ Balance achieved from “lifetime contributions” - wisdom, civic engagement, volunteerism ■ Give and take that must be balanced ■ Roles and resources can be exchanged - between old and young ● Continuity theory ○ Based on limitations of both disengagement and activity theories ○ Neither the struggle to remain active (middle-aged) nor withdrawing from society leads to happiness - coping strategies; same person throughout life ○ Life is a continuum - consistent pattern in life ○ One’s personality (values, habits, commitments, beliefs, preferences) continues throughout life; impacts roles enacted and satisfaction ○ Coping strategies and personality patterns developed earlier in life will predict adjustment in aging ○ Criticism: social context of aging is more important than personality ● Subculture theory ○ Older adults make up a subculture with beliefs, norms, expectations, habits in common - defense response to society ○ Aging subculture = result of loss of status (due to loss of health and mobility) and society’s negative attitudes toward aging ○ Health and mobility define social status - more than SES and education ○ Older adults act best with other older adults → nursing homes ○ Criticism: does not address diversity among older adults; older adults are disadvantaged by declining function ● Age stratification theory ○ Groups of cohorts age collectively in society; have similar experiences ○ High degree of interdependence exists between older adults and context of society ○ Results in reciprocal changes between individuals, age cohorts and society ○ Criticism: is age segregation appropriate? ● Psychological theories of aging ○ Psychological theories - much broader than sociological and biological theories, although influenced by both ○ Include behavioral and developmental aspects of life. Which affect later life ○ Help explain how older adults find meaning in life ● Maslow’s Hierarchy of Human Needs ○ Internal hierarchy of needs that motivate human behavior ○ Five categories from lowest to highest ■ Physiological (basic survival) ■ Security and safety ■ Love and belonging ■ Self-esteem ■ Self-actualization → person reaches full potential; becoming the most one can; ability to pursue goals ● Life course and personal development ○ Jung’s Theory of Individualism ■ Personality develops over the lifespan ■ Oriented toward the external or internal world ■ Need balance between external (youth) and internal forces ■ External forces → internal orientation ■ Successful aging = ability to value oneself; self-acceptance; cope with loss and decline ■ Introversion of aging - meaning of life via inner experiences ○ Gerotranscendence theory ■ Aging → cognitive transformation from materialism and rational views to “oneness with the universe” ● External focus (spirituality unity with universe) ● Acceptance of mortality and death ● Connectedness with preceding/future generations ● Sense of control over life is important ● Framework for long-term care facilities ● External focus of aging ○ Selective Optimization with Compensation (SOC) theory ■ Adults learn to compensate with functional losses through ● Selection - selection of activity ● Optimization - choose activity ● Compensation - seeking alternatives ■ Selective optimization with compensation is a positive coping process ● Person-Environment-Fit theory ○ Useful for exploring optimal environments for older adults with functional limitations and identifying needed modifications in residential settings ○ Functional competence ■ Motor skills and health ■ Cognitive and sensorineural capacity ■ External conditions posed by the environment ■ Age changes competence → function in relation to the environment ○ Personal competence ■ Ego strength ■ Cognition ○ Good for exploring new environments - need of modifications ● Erikson’s 8 stages of life theory - developmental ○ Personality develops in 8 sequential steps with a life-task at each ○ Successful aging depends on ■ Generativity vs. stagnation ■ Ego integrity vs. sense of despair ○ Peck expanded 8th stage ■ Ego differentiation vs work role ■ Body transcendence vs body preoccupation ■ Ego transcendence vs ego preoccupation ■ Current research → role of generativity ■ Help to explain life after retirement, functional decline, mortality O3: Analyze the rationale for using multiple theories of aging for explaining the complex phenomena of the aging process - not sure if this is the answer... ● Gerontological nursing theory ○ Non-nursing theories are typically used to explain phenomena of aging ○ 17 nursing theories (60’s - 90’s) - no application to aging ○ New gerontologic nursing theories are needed ○ Functional consequences theory ○ Theory of thriving ■ Failure to thrive ■ Progressional deterioration ■ Based on frailty O4: Synthesize the life review process (reminiscence) for understanding the meaning of life as expressed in the life stories of an older adult ● Life review (reminiscence) ○ Purpose ■ Share memories of the past ■ Increase self-esteem (uniqueness of individual) ■ Increase socialization ■ Increase reflection and awareness of the past ○ Help older adults to find meaning in memories of life experiences ○ Allows older persons to revisit past experiences → bring past and present together ○ This is important for nurses! ● Steps in reminiscence ○ One-on-one process ■ Focus is on the process ○ Use active listening - who are you, what you’ve done, what you care about are important → acceptance ○ Observe non-verbal signs ○ Ask open-ended questions ○ Use photographs, letters, stories, music, scrapbooks, etc. ○ Focus on values, ways of coping, what matters on a person’s life Module 2C: Age-Related Physiological Changes - Nursing Implications O1: identify age-related physiological changes in older adults from a systems perspective: integumentary, CV, resp, sensory, MS, GU/renal, GI, neuro, and endo ● Aging is heterogeneous! ● Integumentary ○ Skin = largest, most visible organ ○ Epidermis ■ Increased risk of skin cancer ■ Decrease wound-healing ■ Increased susceptibility to infection ■ Flattening of epidermal-dermal junction → increase risk of tearing ○ Dermis ■ Decrease collagen - increase sagging and wrinkling ■ Decrease pain sensation - increase injury ○ Subcutaneous layer (hypodermis) ■ Decrease SC tissue → decrease insulation, protection, and decrease thermoregulation ■ Decrease fat → increase injury and bruising ■ Decrease sebaceous glands → drying of skin, itching ■ Decrease vitamin D absorption → osteoporosis ○ RN interventions - covers O2 ■ Focus on protecting skin from injury ● Daily skin inspection with care assessment and documentation ● Protect and prevent tearing ● Maintain hydration and nutrition ● Moisturize dry skin ● Frequent position changes if immobile ● heat/cold intolerance ● Do not rely on verbalization of pain - inspect ● Monitor healing of wound ● CV - heart muscle and blood vessels ○ Enlarging chambers/LVH (myocardial thickening) ■ Increase resting HR ■ Decrease max HR (with exercise) ○ Orthostatic hypotension ■ Decrease in elasticity and recoil of arteries ○ Arteriosclerosis - with/without vascular disease ■ Atherosclerosis ■ LDL elevation ■ Systolic and diastolic BP increase ○ Venous changes - valve stiffness (edema) ○ Decrease in CO ○ RN implications - covers O2 ● Resp ■ Monitor blood pressure elevation and fluid overload ■ Exercise good - as tolerated ■ Watch for orthostasis - especially with antihypertensive ■ Slow down changes of position ● Supine to sitting ● Sit to stand ■ Check for dependent edema - is common ● Not pitting (+1 to +4) ■ Assess smoking/exposure to environmental pollutants ■ Encourage: stress management and weight control/nutrition ○ Weakened inspiratory and expiratory muscles - increase stiffening of chest wall ■ Decreased lung expansion (decrease tidal volume) ■ Decrease vital capacity ■ Increased residual lung volume ○ Less efficient gas exchange ■ Decrease in alveolar SA - decrease PaCO2 (ABG) ○ Decrease cough reflex, ciliary function, number of functional alveoli ○ RN implications - covers O2 ■ Food/fluid in a supine position are DANGEROUS - upright posture for intake ■ Encourage physical activity as tolerated ■ Encourage regular deep breathing and coughing if prolonged bed rest or resp infection ■ Monitor for atypical presentation ■ Immunization - flu and pneumonia ● Vision changes ○ Presbyopia - decreased visual acuity (4th decade) ○ Increase glare sensitivity ○ Lens of eye yellows ○ Loss of accomodation (dark/light) ○ Decrease color discrimination ○ Decrease peripheral and night vision ○ Decrease contrast sensitivity ○ Vision loss - NOT NORMAL ■ Investigate any vision loss - may be correctable ○ RN implications - covers O2 ■ Good lighting for reading, safe mobility and function ■ Larger font for print, high contrast (black and white), block style printing ■ Avoid cursive print ■ Glasses ■ Magnifiers ● Hearing changes ○ Increased cerumen in canals ○ Hearing loss increases with age ■ Presbycusis (sensorineural) ■ High frequency hearing loss = most common; soft consonants (“T and D” - “S and F”) ○ RN implications - covers O2 ■ Assess for hearing prior to speaking loudly ■ Hearing assistive devices (fall risk) ■ Lower the pitch/tone of voice ■ Speak directly to the older adult ■ Reduce background noise ● Musculoskeletal changes ○ Loss of muscle mass (sarcopenia) and increase fat/muscle ratio ○ Increase connective tissue ○ Decrease synovial fluids in joints → decrease joint mobility ○ Skeletal changes ■ Decrease bone quality and strength - decrease bone mineral density ■ Loss of height (2-3 inches) ■ Kyphosis ○ Arthritis is not normal part of aging! ○ RN implications - covers O2 ■ Assess activity, mobility, gait, balance ■ Prevent falls (assess risk) ■ Daily activity - out of bed: maintain muscle, strength and balance ● Encourage weight bearing mobility ■ Promote safe walking: proper footwear, avoid clutter pathway (wider base of support needed) ● Genitourinary/renal changes ○ Kidneys: decreased GFR (renal function) ■ Decreased blood flow to kidneys ■ Decreased size and function ■ Decreased GFR (impaired mobility to concentrate urine) ○ Bladder: increase involuntary bladder contractions and decrease size ■ Increased nocturnal diuresis ■ Decrease urine flow rate, increase residual urine ○ Incontinence is not normal! ○ Urethral shortening - increase UTi, especially in women ○ RN implications - covers O2 ■ Physical exam and history: morbidity, meds, surgeries, GU, GYN, diet (), constipation, continence hx ■ Prevent dehydration - stay hydrated ■ Medications that require renal excretion may need to be dose adjusted for age ■ Increase toileting frequency (less ability to delay) ■ Prevent incontinence ● Gastrointestinal changes ○ GI track overall, well-preserved ○ Upper GI: mouth, esophagus, stomach ■ Decrease appetite and difficulty masticating ■ Decrease smell, thirst, and taste ■ Decrease tooth enamel (brittle) and dentin ■ Diminished oral muscle strength ■ Dry mouth ○ Less effective swallowing (dysphagia) ■ Decreased esophageal propulsion and emptying ○ Stomach - some changes, not significant ○ Atrophy of bowel mucosa ■ Slows absorption - proteins, minerals, fats, carbs, vitamins ■ Decrease absorption of Ca, lactose, Vit D, zinc, B12, glucose, amino acids, iron ■ Increase bacterial overgrowth → malabsorption and malnutrition ○ Large intestine ■ Increase colonic transit time: increase risk of constipation ■ Constipation is NOT NORMAL ○ Liver ■ Decrease blood flow ○ RN implications - covers O2 ■ Check dietary preferences, teeth, mastication, swallowing ■ Maintain upright position if possible ■ Hydration critical for regular bowel movements ■ Prevent and assess for constipation: monitor meds (esp narcotic meds) ■ Diet that has fiber, fruits, vegetables ■ Daily physical activity essential ■ Smaller, more frequent meals ■ Glasses, hearing aids, use of utensils ■ Monitor pain and meds ● Nervous system changes ○ Central nervous system ■ Decrease neurons, brain weight and size ■ Decrease neurotransmitters ○ Peripheral nervous system → risk for injury ■ Loss of motor neurons ■ Decreased vibratory sensation ■ Decrease tactile sensitivity ■ Decrease proprioception and “righting reflex” ■ Increase body sway ○ Autonomic nervous system changes ? ○ RN implications - nervous system - covers O2 ■ Gait and balance assessments - use of walking aids as needed for safety ■ Inspect feet daily ■ Caution with heat/cold applications ■ Orient frequently, use memory aides and provide social engagement ■ Use principles of patient education ■ Significant memory loss is not normal ○ RN implications - endocrine - covers O2 ■ Thyroid gland decreases in size ● Healthy older adults = little impact ■ Decrease pancreatic beta cell function ● Insulin resistance (monitor DM) ■ Increase ADH (Na loss and hyponatremia) ■ Decrease melatonin → can contribute to sleep problems ● Recognizing and responding to age-related physiological change ○ Assess thoroughly - individualized care plan ○ Reduce safety risk and promote health ○ Improve older adults QOL ○ Age-related changes - major contributor of geriatric syndromes Module 3A: The Hospital Experience for Older Adults and Atypical Presentation of Illness O1: describe risk factors and causes of atypical presentation of illness (API) ● Acute illness often leads to ○ Atypical presentation of illness ○ Cascading latrogenesis - spiraling, unintended decline of health ● Iatrogenic complications - extremely common in hospitalized older adults...with geriatric syndromes, complex illnesses and long lengths of stay ● Risk factors ○ Age: 60% of frail older adults present with API; highest in oldest (85 or older) and frail ■ Age-related changes ■ Diminished physical and cognitive function ○ Complex co-morbidities and/or polypharmacy ○ Medical treatment and interventions ○ Unresolved and multiplying geriatric syndromes O2: Explain clinically relevant signs and symptoms of atypical presentation of illness in older Adults ● Vague presentation of illness ● Altered presentation of illness - mild pain, weakness ● Non-presentation of illness - no typical symptoms ● Examples ○ Acute confusion (delirium) ○ Failure to eat or drink ○ Afebrile (with or without leukocytosis) ○ Lack of pain with typical illness (gastric ulcer) ○ Urinary incontinence ○ Reduced mobility ○ Generalized weakness ○ Falling ○ Fatigue O3: recognize outcomes of API ● Failure to recognize s/s of API affects health outcomes ○ Morbidity and mortality ○ Lack of treatment ○ Over treatment ○ Inappropriate treatment ● Leads to ○ Increase cost ○ Decrease QOL ○ Decrease quality of care O4: explain approaches of assessing and responding to API ● Important systems of body with age-related changes to assess ○ CV ○ Neuro ○ Immunologic ● Lack of recognition and treatment of API results in under treatment, over treatment, inappropriate treatment or no treatment - can be life threatening O5: discuss surgical considerations in older adults ● Surgery is common in older adults: more than 55% of all surgeries occur with patients 65 or older ● While surgery is safer now, older adults experience a disproportionate majority of postoperative morbidity and mortality ● Surgical procedures should be pursued only if consistent with patient-oriented goals ● Must consider: goals, disease burden, function, surgical risk ○ Patient goals of care should be elicited ● Preoperative care must be individualized because ○ Most older people have one or more chronic conditions that influence perioperative care, either directly or through the meds they use ○ Not all organ systems age at the same rate, even within an individual ○ As a result of normal aging, multiple organ systems may have limited physiologic reserve ● Age-related changes influence perioperative care ○ Examples ■ Cardiac and vascular stiffening complicate fluid management ■ Decreased thermoregulation → increased risk of perioperative hypothermia ■ Stiffening of thoracic cage and diminished ciliary function → decreased pulmonary reserve ■ Altered body composition, decreased kidney function, hepatic blood flow, and hepatic enzyme activity → changes in pharmacokinetic of drugs (ADME) ● Preoperative assessment - risk of delirium ○ Risk factors in noncardiac surgery ■ Age 70 or older ■ Cognitive impairment ■ Limited physical function ■ History of alcohol abuse ■ Abnormal serum sodium, potassium, or glucose ■ Intrathoracic surgery or abdominal aneurysm surgery ○ The most important intraoperative risk factor for delirium is blood loss ● Preoperative care should be individualized ○ Not all organ systems age at the same rate, even within an individual ○ Most older people have one or more chronic conditions that influence perioperative care, either directly or through the meds they use ○ Thus, older adults require thorough and individualized preoperative care, and often benefit from a multidisciplinary approach O6: analyze consequences of immobility in hospitalized older adults ● 72% of hospitalized patients do not ambulate at all ● Reasons for lack of ambulation ○ Fear of falling (56%); hospital disorientation ○ Mobility not emphasized by providers ○ Afraid will “miss the doctor” on rounds ○ Environmental deterrents (clutter, noise) ○ Lack of mobility and sensory aids (glasses, canes, walkers) ○ Hospital admission risk profile (HARP) ● Why do healthcare professionals think bedrest is beneficial? ○ Promote rest and recovery ○ Reduce ■ Metabolic rate and energy expenditure-quiz question (I asked the profs to reword this question because it was worded as if research suggested immobility for this reason, but it’s the opposite) ■ Oxygen consumption ■ CO2 production ■ CV workload ■ Pain ■ Strain on healing tissues ○ Prevent falls ● Consequences of immobility ○ Decline in function ○ Thromboembolic disease ○ Atelectasis ○ Pressure ulcers ○ Skeletal muscle atrophy and weakness ○ Joint contractures - if not exercising in bed ○ Constipation ○ Orthostasis ○ Pneumonia ○ Falls (weakness, orthostatic hypotension) ● Functional decline = strong predictor of mortality, greater prognostic value than disease co-morbidity or severity, disease staging and DRGs (dx-related group) combined ○ Lose 5% of strength per day ○ Lose leg strength the most ● Hazards of hospitalizations - hospital-associated disability ○ Once hospitalized, older patients are at high risk of loss of independence and institutionalization ○ Among hospitalized medical patients 70 or older, approximately one third are discharged with a disability that was not present 2 weeks before admission, a condition referred to as hospitalization-associated disability (HAD) ○ Patients at risk of HAD are easily identified on admission ● Risk factors (for new-onset disability in hospitalized patients 70 or older) include ○ Age, number of dependencies in ADLs and IADLs, mobility 2 weeks before admin, metastatic cancer or stroke, severe cognitive impairment, and hypoalbuminemia ● Higher risk scores predicted more severe disability, greater likelihood of nursing-home placement, and worse survival ● Clinicians play a critical role in educating patients and families to engage in function-promoting activity, preventing functional decline O7: discuss disability prevention programs for hospitalization ● Identify those at risk ● Assess pre-hospital functional status ● Ambulate - get appropriate activity orders ○ Exercise is good ○ Beds are for sleeping ● Avoid contraindicated meds ● Avoid catheters when possible ● Provide adequate hydration and nutrition ● Hospitalized intervention programs to prevent loss of function and disability ○ Acute care units for elders ■ Special hospital environment ■ PCC to promote function ■ Early discharge planning - goal = home ■ Decrease avoidable complications ■ Better process of care ○ Hospital elder life program ■ Nonpharmacologic interventions to maintain and improve function ● Disparities of hospital care ○ Minority patients are less likely than whites to be treated at high-volume hospitals for services for which high volume is associated with better outcomes ○ Disparity is largest for cancer surgeries and CV procedures ○ Hospitals in the bottom quintile on most quality measures served a significantly higher percentage of minority patients than hospitals in the top quintile ● Hospitalized older patients receive less costly treatment ○ Compared with younger adults, seriously ill patients 80 or older ■ Fewer invasive procedures ■ Less costly, less resource-intensive hospital care ○ Those differences do not reflect differences in patient’s severity of illness or preferences for life- extending care ○ Irrespective of the patient’s age, the best guides to assessment and management are the clinical circumstances and the patient’s preferences O8: review best practice approaches for reducing hospital functional decline in at-risk older adults ● Conduct a comprehensive, culturally appropriate interdisciplinary geriatric assessment of physical, psychosocial and functional status at admission with at-risk older adults ● Encourage activity during hospitalization with structured exercise, progressive resistance, strength training, and walking programs, in coordination with rehab therapies (physical and occupational) ● Implement early mobilization for acute and critically ill patients based on established protocols ● Ensure assistive devices are in use - hearing aids in place, glasses on, walker or cane ● Teach use of proper footwear to encourage mobility and prevent falls ● Ensure use of environmental enhancements for eldercare including handrails, un-clutter hallways, large clocks and calendars, elevated toilet seats, and door levers ● Integrate established protocols aimed at reducing the risk for geriatric syndromes and improving self care, continence, nutrition, mobility, sleep, skin care, cognition, and minimizing adverse effects of selected procedures (urinary cath) ● Evaluate the appropriateness of meds, minimizing the use of sedative-hypnotic meds and ensuring correct med dosing; monitor responses to drug therapy and ensure med reconciliation during hospitalization and at discharge ● Promote safety while encouraging independence and maintaining dignity ● Integrate geriatric interdisciplinary team with use of geriatric specialists ● Consider participation in best practice models for elder care such as acute care for elderly (ACE) and HELP ● Never events - not covered by Medicare ○ Medicare payment for inpatient care is based on dx and procedures that are assigned dx-related group (DRG) codes ■ Prior to 2008, hospitals received greater reimbursement for the care of the patient who developed complications that led to a costlier DRG ○ In 2008, CMS mandated non-payment for hospitalized-acquired “never events,” conditions that ■ Are high cost/high volume ■ Result in reassignment to a higher reimbursed DRG when designated as secondary dx ■ Are reasonably preventable through application of evidence-based interventions ○ 2008 “never events” include ■ Surgical object left in patient ■ Air embolism ■ Blood incompatibility ■ Catheter-associated UTI (CAUTI) ■ Hospital-acquired stage II or IV pressure ulcer (HAPU) ■ Vascular catheter-associated infection ■ Mediastinitis after coronary artery bypass grafting ■ Falls and trauma ○ Three conditions designated “never events” for which older hospitalized adults are known to be at greater risk of developing are falls, HAPU, and CAUTI O9: complete the case study (Mrs. J) and apply principles learned in this module (LAPP) ● Q1: Of all the 5 problems identified on your problem list, which one(s) might be considered of an acute onset for Mrs. J ○ Problems 1, 2, 3 and 4 are all considered of new onset. As the most reliable historian, Doris confirmed that her mother was functioning normally without medical problems, except for a history of age‐related forgetfulness until recently - confusion, urinary incontinence, fall, and decline in ADL function. ● If problems 1,2,3,4 were all preceded by the prefix‐”acute”, re‐write the problem list and plan of care: ○ Acute confusion ○ Acute urinary incontinence ○ Acute fall ○ Acute decline in ADL function ● Q2: How does the plan of care change now that each of Mrs. J’s major problems are re‐focused as acute in onset? ○ An acute problem in an older adult is a significant problem, possibly a medical emergency requiring immediate attention. Doris reports all 4 problems of recent onset (within 3 weeks). The plan of care changes to focus on determining the underlying causes of these acute problems and to treat them. ● Q3: How does Mrs. J’s current medical problem threaten her independence? ○ Mrs. J is experiencing an acute confusion state which has resulted in paranoia and increasing forgetfulness with inability to recognize her daughter. This cognitive change has rendered her unable to accurately and safely perform basic activities of daily living. Her appetite is poor and she consumes very little. Hence she requires regular assistance in ADL’s and constant supervision. Because of her cognitive and functional changes, Mrs. J is at risk for long‐term institutionalization unless the causes are identified and treated. ● Q4: What is the best option for addressing this problem? ○ Given Mrs. J’s new arrival to the nursing home, there are two options for the plan of care: ■ Transfer Mrs. J to an emergency department for additional evaluation. OR ■ If Mrs. J is medically stable, pursue an aggressive work up at the current facility. ○ A decision was made with the primary physician and the daughter to admit Mrs. J to the nursing home and evaluate all of these acute changes in her condition. ● Q5: What other subjective data do you need to gather? ○ Several pieces of historical information are missing. More information is needed about the onset of the acute confusion, pattern, aggravating & alleviating factor, associated symptoms of hallucinations, delusions or suicidal thoughts. Given the new fall, important questions to review with Doris include: Has there been any recent head injury? Accidental ingestion of medication or poison? Head trauma or acute poisoning can cause confusion. ○ More detail about the use of haloperidol needs to be obtained, for instance, under what circumstances was it started? How long has Mrs. J been taking it and has it contributed to the paranoia? Has it helped or worsened the confusion? ○ Also missing from the medical record is the timing or sequence of all of these new problems. What occurred first: the fall?...the incontinence?...or the confusion? ● Q6: What objective data do you need to gather for Mrs. J? ○ A comprehensive physical assessment of Mrs. J is needed. Starting with vital signs, assessment of oral hydration – serum electrolytes, neurological assessment including gait and balance, serial cognitive assessments to look for focal deficits, head trauma. A baseline electrocardiogram, chest x‐ray, urinalysis and thyroid function studies are also part of the acute confusion assessment. Intake and output is needed. ● Additional Subjective & Objective Data ○ According to Doris, 3 week sago, her mother became increasingly confused over a 2 day period, while also experiencing urinary frequency. She was running to the bathroom, slipped and fell on the floor in front of Doris on the tile floor, landing on her knees. There was no syncope, head or extremity injury. She telephoned the physician, haloperidol was prescribed for 3 weeks. Since then the confusion has increased, paranoia started and now Mrs. J is totally incontinent, needing help to even find the bathroom. Doris can no longer manage and begins to cry. ○ On physical assessment, Mrs. J is a bit apprehensive and guarded. Temp‐ 98 degrees P‐80 R‐20 BP 90/60. Head‐ no trauma; mouth‐ dry parched membranes, tongue furrowed. Neck‐ flat neck veins. Lungs‐ clear CV‐ apical regular at 80 beats/minute. Extremities dry. Neurological‐ intact, DTR symmetrical, no focal deficits, decreased muscular strength‐distal. Repeat MMSE 24/30. EKG‐ normal sinus rhythm. The chest x‐ray is normal, thyroid studies are normal. U/A shows +1 bacteria, leukocyte esterace +; WBC + and microscopic blood present. ● Q7: Based on the subjective and objective data, what is the new problem list & plan of care? ○ Urinary tract infection, contributing to urinary incontinence and falls and acute confusion ■ Plan ● Start antibiotic, repeat u/a in 1 week ● Stop haloperidol and observe – repeat MMSE & CAM ○ Urinary frequency due to infection ‐ causing acute confusion with decreased fluid intake ■ Plan ● Monitor intake and output ● Encourage oral fluids ● Assist to use toilet regularly ● After a 7 day course of oral antibiotics, Mrs. J is no longer incontinent of urine, she has regained her appetite. There have been no falls. She is able to care for herself in her room at the facility. The repeat MMSE is 30/30. Mrs. J wants to know when she can go home. ○ Dx data ■ Two weeks after an admission to a nursing facility for respite and most likely long term care, Mrs. J went home to live with her daughter. ■ She followed up with an office visit to her PCP and repeat urinalysis showed the presence of blood once again. A kidney ultrasound was ordered, revealing a small renal calculi which responded to conservative treatment. Once again, she drives to her part‐time job in the local library. ● Case Study Take Home Points ○ Atypical presentation of UTI classically presents in older adults with cognitive changes, loss of appetite and/or new onset of urinary incontinence. Note: Mrs. J had all of these symptoms plus she did not develop a fever [atypical presentation of an infection in older adults often presents without a fever or even leukocytosis on CBC] ○ Any condition causing a generalized weakness such as an infection can lead to a fall. ○ Urinary incontinence can lead to an accidental fall when a person becomes incontinent on route the toilet. ○ Older adults presenting on admission to a nursing home with a history of confusion are presumed to have Alzheimer’s Disease. In this case, the acute onset of memory problems speaks against a diagnosis of Alzheimer’s disease [which presents gradually]. ○ Acute confusion can occur (or worsen) from use of psychotropic agents. When in doubt, it is best to eliminate any offending medication. ○ Acute confusion, as part of an atypical presentation, is reversible if detected early. The nurse has a critical role in identifying signs and symptoms that may be indicative of